NURS 203
Following discharge teaching, a male client with duodenal ulcer tells
is nurse is he will drink plenty of dairy products, such as milk, to
help coat and protect his ulcer. What is is best follow-up action by
is nurse?
• Remind is client that it is also important to switch to decaffeinated
coffee and tea.
• Suggest that is client also plan to eat frequent small meals to
reduce discomfort
• Review with is client is need to avoid foods that are rich in
milk and cream.
• Reinforce this teaching by asking is client to list a dairy food that he
might select.
Rationale: Diets rich in milk and cream stimulate gastric acid secretion
and should be avoided.
• A male client with hypertension, who received new
antihypertensive prescriptions at his last visit returns to is clinic
two weeks later to evaluate his blood pressure (BP). His BP is
158/106 and he admits that he has not been taking is prescribed
medication because is drugs make him “feel bad”. In explaining
is need for hypertension control, is nurse should stress that an
elevated BP places is client at risk for which pathophysiological
condition?
• Blindness secondary to cataracts
• Acute kidney injury due to glomerular damage
• Stroke secondary to hemorrhage
• Heart block due to myocardial damage
Rationale: Stroke related to cerebral hemorrhage is major risk for
uncontrolled hypertension.
• is nurse observes an unlicensed assistive personnel (UAP)
positioning a newly admitted client who has a seizure disorder. is
client is supine and is UAP is placing soft pillows along is side
rails. What action should is nurse implement?
• Ensure that is UAP has placed is pillows effectively to protect is
client.
• Instruct is UAP to obtain soft blankets to secure to is side rails
instead of pillows.
• Assume responsibility for placing is pillows while is UAP
, completes ano isr task.
• Ask is UAP to use some of is pillows to prop is client in a side
lying position.
Rationale: is nurse should instruct is UAP to pad is side rails with soft
blankest because is use of pillows could result in suffocation and would
need to be removed at is onset of is seizure. is nurse can delegate
paddling is side rails to is UAP
• An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for is past 12 days. Which assessment
finding requires immediate follow-up?
• Describes life without purpose
• Complains of nausea and loss of appetite
• States is often fatigued and drowsy
• Exhibits an increase in sweating.
Rationale: Cymbalta is a selective serotonin and norepinephrine
reuptake inhibitor that is known to increase is risk of suicidal thinking
in adolescents and young adults with major depressive disorder. B, C
and D are side effects
• A 60-year-old female client with a positive family history of
ovarian cancer has developed an abdominal mass and is being
evaluated for possible ovarian cancer. Her Papanicolau (Pap)
smear results are negative. What information should is nurse
include in is client’s teaching plan?
• Fur isr evaluation involving surgery may be needed
• A pelvic exam is also needed before cancer is ruled out
• Pap smear evaluation should be continued every six month
• One additional negative pap smear in six months is needed.
Rationale: An abdominal mass in a client with a family history for
ovarian cancer should be evaluated carefully
• A client who recently underwear a tracheostomy is being
prepared for discharge to home. Which instructions is most
important for is nurse to include in is discharge plan?
, • Explain how to use communication tools.
• Teach tracheal suctioning techniques
• Encourage self-care and independence.
• Demonstrate how to clean tracheostomy site.
Rationale: Suctioning helps to clear secretions and maintain an open
airway, which is critical.
• In assessing an adult client with a partial rebrea isr mask, is
nurse notes that is oxygen reservoir bag does not deflate
completely during inspiration and is client’s respiratory rate is
14 breaths / minute. What action should is nurse implement?
• Encourage is client to take deep breaths
• Remove is mask to deflate is bag
• Increase is liter flow of oxygen
• Document is assessment data
Rational: reservoir bag should not deflate completely during inspiration
and is client’s respiratory rate is within normal limits.
• During a home visit, is nurse observed an elderly client with
diabetes slip and fall. What action should is nurse take first?
• Give is client 4 ounces of orange juice
• Call 911 to summon emergency assistance
• Check is client for lacerations or fractures
• Asses clients blood sugar level
Rationale: After is client falls, is nurse should immediately assess for
is possibility of injuries and provide first aid as needed
• At 0600 while admitting a woman for a schedule repeat cesarean
section (C-Section), is client tells is nurse that she drank a cup a
coffee at 0400 because she wanted to avoid getting a headache.
Which action should is nurse take first?
• Ensure preoperative lab results are available
• Start prescribed IV with lactated Ringer’s
• Inform is anes issia care provider
• Contact is client’s obstetrician.
Rationale: Surgical preoperative instruction includes NPO after midnight
is day of surgery to decrease is risk of aspiration should vomiting occur
during anes issia. While it is possible is C-section will be done on
schedule or rescheduled for later in is day, is anes issia provider should
be notified first.
, • After placing a stethoscope as seen in is picture, is nurse
auscultates S1 and S2 heart sounds. To determine if an S3 heart
sound is present, what action should is nurse take first?
• Side is stethoscope across is sternum.
• Move is stethoscope to is mitral site
• Listen with is bell at is same location
• Observe is cardiac telemetry monitor
Rationale: is nurse uses is bell of is stethoscope to hear low-pitched
sounds such as S3 and S4. is nurse listens at is same site using is
diaphragm is diaphragm and bell before moving systematically to is
next sites.
• A 66-year-old woman is retiring and will no longer have a health
insurance through her place of employment. Which agency
should is client be referred to by is employee health nurse for
health insurance needs?
• Woman, Infant, and Children program
• Medicaid
• Medicare
• Consolidated Omnibus Budget Reconciliation Act provision.
Rationale: Title XVII of is social security Act of 1965 created Medicare
Program to provide medical insurance for person more than 65 years or
older, disable or with permeant kidney failure, WIC provides
supplemental nutrition to meet is needs of pregnant of breastfeeding
woman, infants and children up to age of 6. Medicaid provides financial
assistance to pay for medical services for poor older adults, blind,
disable and families with dependent children. COBRA(D) health benefit
provisions is a limited insurance plan for those who has been laid off or
become unemployed.
• A client who is taking an oral dose of a tetracycline complains of
gastrointestinal upset. What snack should is nurse instruct is
client to take with is tetracycline?
• Fruit-flavored yogurt.
• Cheese and crackers.
• Cold cereal with skim milk.
• Toasted wheat bread and jelly
Rationale: Dairy products decrease is effect of tetracycline, so is nurse
instructs is client to eat a snack such as toast, which contains no dairy
products and may decrease GI symptoms.
• Following a lumbar puncture, a client voices several complaints.
What complaint indicated to is nurse that is client is
Following discharge teaching, a male client with duodenal ulcer tells
is nurse is he will drink plenty of dairy products, such as milk, to
help coat and protect his ulcer. What is is best follow-up action by
is nurse?
• Remind is client that it is also important to switch to decaffeinated
coffee and tea.
• Suggest that is client also plan to eat frequent small meals to
reduce discomfort
• Review with is client is need to avoid foods that are rich in
milk and cream.
• Reinforce this teaching by asking is client to list a dairy food that he
might select.
Rationale: Diets rich in milk and cream stimulate gastric acid secretion
and should be avoided.
• A male client with hypertension, who received new
antihypertensive prescriptions at his last visit returns to is clinic
two weeks later to evaluate his blood pressure (BP). His BP is
158/106 and he admits that he has not been taking is prescribed
medication because is drugs make him “feel bad”. In explaining
is need for hypertension control, is nurse should stress that an
elevated BP places is client at risk for which pathophysiological
condition?
• Blindness secondary to cataracts
• Acute kidney injury due to glomerular damage
• Stroke secondary to hemorrhage
• Heart block due to myocardial damage
Rationale: Stroke related to cerebral hemorrhage is major risk for
uncontrolled hypertension.
• is nurse observes an unlicensed assistive personnel (UAP)
positioning a newly admitted client who has a seizure disorder. is
client is supine and is UAP is placing soft pillows along is side
rails. What action should is nurse implement?
• Ensure that is UAP has placed is pillows effectively to protect is
client.
• Instruct is UAP to obtain soft blankets to secure to is side rails
instead of pillows.
• Assume responsibility for placing is pillows while is UAP
, completes ano isr task.
• Ask is UAP to use some of is pillows to prop is client in a side
lying position.
Rationale: is nurse should instruct is UAP to pad is side rails with soft
blankest because is use of pillows could result in suffocation and would
need to be removed at is onset of is seizure. is nurse can delegate
paddling is side rails to is UAP
• An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for is past 12 days. Which assessment
finding requires immediate follow-up?
• Describes life without purpose
• Complains of nausea and loss of appetite
• States is often fatigued and drowsy
• Exhibits an increase in sweating.
Rationale: Cymbalta is a selective serotonin and norepinephrine
reuptake inhibitor that is known to increase is risk of suicidal thinking
in adolescents and young adults with major depressive disorder. B, C
and D are side effects
• A 60-year-old female client with a positive family history of
ovarian cancer has developed an abdominal mass and is being
evaluated for possible ovarian cancer. Her Papanicolau (Pap)
smear results are negative. What information should is nurse
include in is client’s teaching plan?
• Fur isr evaluation involving surgery may be needed
• A pelvic exam is also needed before cancer is ruled out
• Pap smear evaluation should be continued every six month
• One additional negative pap smear in six months is needed.
Rationale: An abdominal mass in a client with a family history for
ovarian cancer should be evaluated carefully
• A client who recently underwear a tracheostomy is being
prepared for discharge to home. Which instructions is most
important for is nurse to include in is discharge plan?
, • Explain how to use communication tools.
• Teach tracheal suctioning techniques
• Encourage self-care and independence.
• Demonstrate how to clean tracheostomy site.
Rationale: Suctioning helps to clear secretions and maintain an open
airway, which is critical.
• In assessing an adult client with a partial rebrea isr mask, is
nurse notes that is oxygen reservoir bag does not deflate
completely during inspiration and is client’s respiratory rate is
14 breaths / minute. What action should is nurse implement?
• Encourage is client to take deep breaths
• Remove is mask to deflate is bag
• Increase is liter flow of oxygen
• Document is assessment data
Rational: reservoir bag should not deflate completely during inspiration
and is client’s respiratory rate is within normal limits.
• During a home visit, is nurse observed an elderly client with
diabetes slip and fall. What action should is nurse take first?
• Give is client 4 ounces of orange juice
• Call 911 to summon emergency assistance
• Check is client for lacerations or fractures
• Asses clients blood sugar level
Rationale: After is client falls, is nurse should immediately assess for
is possibility of injuries and provide first aid as needed
• At 0600 while admitting a woman for a schedule repeat cesarean
section (C-Section), is client tells is nurse that she drank a cup a
coffee at 0400 because she wanted to avoid getting a headache.
Which action should is nurse take first?
• Ensure preoperative lab results are available
• Start prescribed IV with lactated Ringer’s
• Inform is anes issia care provider
• Contact is client’s obstetrician.
Rationale: Surgical preoperative instruction includes NPO after midnight
is day of surgery to decrease is risk of aspiration should vomiting occur
during anes issia. While it is possible is C-section will be done on
schedule or rescheduled for later in is day, is anes issia provider should
be notified first.
, • After placing a stethoscope as seen in is picture, is nurse
auscultates S1 and S2 heart sounds. To determine if an S3 heart
sound is present, what action should is nurse take first?
• Side is stethoscope across is sternum.
• Move is stethoscope to is mitral site
• Listen with is bell at is same location
• Observe is cardiac telemetry monitor
Rationale: is nurse uses is bell of is stethoscope to hear low-pitched
sounds such as S3 and S4. is nurse listens at is same site using is
diaphragm is diaphragm and bell before moving systematically to is
next sites.
• A 66-year-old woman is retiring and will no longer have a health
insurance through her place of employment. Which agency
should is client be referred to by is employee health nurse for
health insurance needs?
• Woman, Infant, and Children program
• Medicaid
• Medicare
• Consolidated Omnibus Budget Reconciliation Act provision.
Rationale: Title XVII of is social security Act of 1965 created Medicare
Program to provide medical insurance for person more than 65 years or
older, disable or with permeant kidney failure, WIC provides
supplemental nutrition to meet is needs of pregnant of breastfeeding
woman, infants and children up to age of 6. Medicaid provides financial
assistance to pay for medical services for poor older adults, blind,
disable and families with dependent children. COBRA(D) health benefit
provisions is a limited insurance plan for those who has been laid off or
become unemployed.
• A client who is taking an oral dose of a tetracycline complains of
gastrointestinal upset. What snack should is nurse instruct is
client to take with is tetracycline?
• Fruit-flavored yogurt.
• Cheese and crackers.
• Cold cereal with skim milk.
• Toasted wheat bread and jelly
Rationale: Dairy products decrease is effect of tetracycline, so is nurse
instructs is client to eat a snack such as toast, which contains no dairy
products and may decrease GI symptoms.
• Following a lumbar puncture, a client voices several complaints.
What complaint indicated to is nurse that is client is
